[Vaccination in childhood in France: Current issues and challenges]

Vaccination in childhood in France : current issues and challenges. Children are a priority target for immunization programs, in large part because the most contagious vaccine- preventable diseases affect children early in life. If vaccination coverage of infants is very high and consistent with public health objectives, the situation regarding older children and especially adolescents is unsatisfactory. Vaccination coverage against measles and meningococcal C diseases are insufficient, resulting in the occurrence of severe cases, which could have been avoided through better immunization coverage. In adolescents, coverage against hepatitis B and especially papillomavirus are far below the expectation, exposing young adults to contamination by these oncogenic viruses. General practitioners and pediatricians are the cornerstone to increase vaccination coverage. The renewed commitment for the vaccination program of the Ministry of Health and its agencies should give them the support they need, in particular by providing them with tools tailored to their practice.

Implementing efficient and sustainable collaboration between National Immunization Technical Advisory Groups: Report on the 3rd International Technical Meeting, Paris, France, 8-9 December 2014

Many experts on vaccination are convinced that efforts should be made to encourage increased collaboration between National Immunization Technical Advisory Groups on immunization (NITAGs) worldwide. International meetings were held in Berlin, Germany, in 2010 and 2011, to discuss improvement of the methodologies for the development of evidence-based vaccination recommendations, recognizing the need for collaboration and/or sharing of resources in this effort. A third meeting was held in Paris, France, in December 2014, to consider the design of specific practical activities and an organizational structure to enable effective and sustained collaboration. The following conclusions were reached: (i) The proposed collaboration needs a core functional structure and the establishment or strengthening of an international network of NITAGs. (ii) Priority subjects for collaborative work are background information for recommendations, systematic reviews, mathematical models, health economic evaluations and establishment of common frameworks and methodologies for reviewing and grading the evidence. (iii) The programme of collaborative work should begin with participation of a limited number of NITAGs which already have a high level of expertise. The amount of joint work could be increased progressively through practical activities and pragmatic examples. Due to similar priorities and already existing structures, this should be organized at regional or subregional level. For example, in the European Union a project is funded by the European Centre for Disease Prevention and Control (ECDC) with the aim to set up a network for improving data, methodology and resource sharing and thereby supporting NITAGs. Such regional networking activities should be carried out in collaboration with the World Health Organization (WHO). (iv) A global steering committee should be set up to promote international exchange between regional networks and to increase the involvement of less experienced NITAGs. NITAGs already collaborate at the global level via the NITAG Resource Centre, a web-based platform developed by the Health Policy and Institutional Development Unit (WHO Collaborating Centre) of the Agence de Médecine Préventive (AMP-HPID). It would be appropriate to continue facilitating the coordination of this global network through the AMP-HPID NITAG Resource Centre. (v) While sharing work products and experiences, each NITAG would retain responsibility for its own decision-making and country-specific recommendations.

[VACCINATION AGAINST HEPATITIS B: WHAT'S UP?]

The vaccination against hepatitis B has been shown to be effective and safe. 15 years after a scare suggesting a relationship between the HBV vaccine and the development of demyelinating diseases, studies have not confirmed this suspected link. The french HBV vaccination strategy in effect since the 1990's (vaccination of newborns, a catch-up campaign in children and adolescents and vaccination of high risk populations) is well adapted to the existing epidemiological situation. Vaccination coverage in newborns has increased significantly since 2008. Catch-up of children and adolescents is insufficient. The very limited data on vaccination coverage in populations at high risk of HBV suggests that coverage is largely insufficient. The mandatory vaccination of healthcare workers since 1991 has nearly completely eradicated worksite HBV. Nevertheless: persistent circulation of the virus and the risk of healthcare worker-patient transmission, and insufficient coverage justifies continued vaccination and mandatory proof of immunization. Specific vaccination protocols are needed because certain co-morbidities can reduce the probability and strength of the response to the vaccine. The physician should evaluate this risk case-by-case and adapt the vaccination protocol accordingly. Between 2007 and 2012, more than 200 patients have undergone liver transplantation associated with HBV (cirrhosis, hepatocellular carcinoma, fulminant hepatitis). Many of these transplantations could have been avoided thanks to vaccination, and these grafts could have been proposed to other patients.

Vaccination against serogroup B Neisseria meningitidis: Perceptions and attitudes of parents

BACKGROUND

A vaccine against serogroup B Neisseria meningitidis, major cause of bacterial meningitis in children and adults, has recently been developed. In a context of an increasing parental mistrust against vaccinations, understanding the reason for their choices is crucial in order to improve immunization coverage. Our study aimed at evaluating parental attitudes and perceptions towards serogroup B meningococcal invasive disease vaccination.

METHODS

A prospective observational study was conducted in different French independent-practice medical offices (general practitioners and paediatricians) and nurseries between May 1 and December 31, 2013, using a questionnaire distributed in electronic and paper forms to parents having at least one child between the ages of 2 months and 16 years old.

RESULTS

1270 parents were included, of whom 671 (52.8%) spontaneously stated to be in favour of this vaccination. Their choice was mainly justified by the severity of the disease (63.8%) and the desire to protect their child (51.7%). In multivariate analysis, the young age of parents (OR 0.949 per additional year; p<10(-3)), the history of vaccination against serogroup C meningococcal invasive diseases (OR 6.755; p<10(-3)), and the prior knowledge of the vaccine (OR 2.081; p=0.001) were associated with vaccination acceptance. The main reasons for refusal were the lack of hindsight on this new vaccine (50.6%) and the fear of side effects (45.5%). After objective information on the disease and the vaccine, only 6.3% of the entire responding population would refuse to consider vaccination.

CONCLUSIONS

The spontaneous acceptance rate of vaccination against serogroup B meningococcal invasive disease is insufficient. However, after objective information by their physician or public health authorities, only a few parents would in the end be completely resistant.

Strategies for decision-making on vaccine use: the French experience

France enjoys benefits of a good organization of its healthcare system. National Health Insurance is reimbursing vaccines if they are used according to the national recommendation guidelines. Vaccination is the responsibility of the government, advised by its National Immunization Technical Advisory Group (Comité Technique des vaccinations). But France, like many other countries, faces insufficient involvement from the public in immunization programs and, consequently, numerous outbreaks of vaccine-preventable diseases. The French government launched a 5-year national program for improvement in vaccination policy in 2012 to simplify the guidelines, facilitate access to vaccination, invest in research and evaluate its vaccine policy. The role of the public and healthcare professionals to encourage vaccination is crucial for the future.

[The immunization schedule]

Vaccination offers individual and collective protection against a number of infectious diseases. The immunisation schedule is updated every year and published by the French Ministry for Health. In 2013, the schedule was simplified in order to improve the vaccination coverage of the French population. Specific recommendations are made for health professionals.

Clinical presentation of severe viral encephalitis with known causative agents in children: a retrospective study on 16 patients hospitalized in a pediatric intensive care unit (2008-2011)

A retrospective analysis was conducted in a French pediatric hospital in Lyon. Subjects were 16 patients diagnosed with acute viral encephalitis with identified causative agents who were admitted to the pediatric intensive care unit from 2008 to 2011. The median length of stay was 6 days. The outcome was favorable for 77% of the patients. Analysis of biological and clinical findings based on causative agents did not reveal clinical patterns or neurological findings specific to the causal viruses. Nevertheless, uncommon clinical pictures and severe neurological complications were highlighted, in particular for children with influenza-related encephalitis and herpes simplex encephalitis. This case series exemplifies the difficulties, even pitfalls, in establishing a diagnosis of encephalitis, especially in neonates. It points out significant differences in the clinical presentation of encephalitis in children compared with clinical pictures described in previously published large-scale studies on encephalitis mainly conducted in adults.

Knowledge and risk perception of measles and factors associated with vaccination decisions in subjects consulting university affiliated public hospitals in Lyon, France, after measles infection

In 2011, a large number of European countries faced measles outbreaks, France accounting for more than half of the reported cases. The Rhône-Alpes region, located in south-east France, was one of the most affected provinces, with an incidence rate of 97.9 cases per 100 000 inhabitants. We conducted a retrospective survey of adults and parents of children consulting university affiliated public hospitals because of measles infections between January 1, 2010 and September 2012 in Lyon, France. Our main objectives were to evaluate (1) the level of study population knowledge of measles, (2) vaccination practices, and (3) changes in opinion with regard to measles vaccination after disease onset. Overall, 73.64% of patients were not vaccinated or partially vaccinated. The main reason for non-vaccination in children was inappropriate age while among non-vaccinated adults, 29.3% could not give any reason. In total, 29.1% of the responding parents and 24.2% of adult cases were opposed to vaccination "in principle." A large number of patients did not recognize measles as a serious illness and were unaware of its complications. Among parents of infected children, knowledge of transmission mode (odds ratio [OR] = 5.9; 95% confidence interval [95% CI]: 1.64-21.26), perceived severity of measles (OR = 1.5; 95% CI: 1.06-2.13), and absence of hepatitis B vaccination (OR = 0.17; 95% CI: 0.04-0.65) were independently associated with a more positive opinion about measles vaccination after disease onset. In adult patients, low education level (OR = 3.39; 95% CI: 1.03-11.11) and lack of knowledge of sequelae (OR = 10.19; 95% CI: 1.14-91.31) were linked with a more positive opinion. Individuals affected by vaccine-preventable diseases are interesting populations to study disease impact on vaccine perception.

Stroke by carotid artery complete occlusion in Kawasaki disease: case report and review of literature

BACKGROUND

Kawasaki disease is an acute and time-limited systemic vasculitis primarily affecting young children.

PATIENT

We describe an 18-month-old girl with Kawasaki disease who developed cerebral infarction following complete occlusion of her right internal carotid artery.

RESULTS

The occlusion occurred 10 days after the onset of fever, while she was on high-dose aspirin, and the day after she received intravenous immunoglobulin treatment. We present the first literature review on this very rare complication.

CONCLUSION

Stroke is a rare neurological complication in Kawasaki disease. Optimal treatment should be begun as soon as possible after diagnosis. Intravenous immunoglobulins seem to reduce the cerebrovascular complications, but evaluation of hydration status is strongly recommended before performing such treatment.

Measles elimination efforts and 2008-2011 outbreak, France

Although few measles cases were reported in France during 2006 and 2007, suggesting the country might have been close to eliminating the disease, a dramatic outbreak of >20,000 cases occurred during 2008–2011. Adolescents and young adults accounted for more than half of cases; median patient age increased from 12 to 16 years during the outbreak. The highest incidence rate was observed in children <1 year of age, reaching 135 cases/100,000 infants during the last epidemic wave. Almost 5,000 patients were hospitalized, including 1,023 for severe pneumonia and 27 for encephalitis/myelitis; 10 patients died. More than 80% of the cases during this period occurred in unvaccinated persons, reflecting heterogeneous vaccination coverage, where pockets of susceptible persons still remain. Although vaccine coverage among children improved, convincing susceptible young adults to get vaccinated remains a critical issue if the target to eliminate the disease by 2015 is to be met.

How French physicians manage with a future change in the primary vaccination of infants against diphtheria, tetanus, pertussis and poliomyelitis? A qualitative study with focus groups

Background

As in other European countries, the French vaccination schedule changes according to epidemiological and socio-economic situations. Further changes are planned for 2013, including the withdrawal of one dose for primary vaccination against diphtheria, tetanus, polio, pertussis and Haemophilus influenzae. A partnership between the French Technical Vaccination Committee and the French Institute for Health and Medical Research designed a study to assess primary care physicians’ agreement about this modification.

Methods

Qualitative study with focus groups and semi-structured interviews in France. Four focus groups were conducted with physicians, supplemented by four individual interviews.

Results

The physicians of the survey had accepted the suggested vaccination schedule well. A few concerns had been underlined: fear of less follow-up care for infants resulting from the removal of one visit driven by the primary vaccination; fear of loss of vaccine efficacy; suspicion of the existence of financial arguments at the origin of this change; and adjustment to current vaccination schedule. Several suggestions were made: providing strong support from health authorities; developing stable and simple recommendations; providing effective tools for monitoring patient’s vaccination status.

Conclusions

Physicians’ opinions suggested a good acceptance of a possible change about primary vaccination against diphtheria, tetanus, polio, pertussis and Haemophilus influenzae. Physicians’ suggestions resulted from this qualitative study on a new vaccination schedule. It showed how that their involvement was feasible for preparing the implementation of a new vaccination schedule.

[Influenza infection and pregnancy]

Pregnant woman have an increased risk of respiratory complications and hospitalization related to influenza. The flu, like any systemic infection, may also be responsible for uterine contractions constituting a threat of miscarriage or premature labor according to gestational age at which it occurs. There is no specific recommendation regarding the management of influenza-like illness in pregnant women, but a nasopharyngeal sample can be performed in the presence of respiratory or general symptoms occurring during an epidemic to search influenza and establish if a specific treatment with oseltamivir (Tamiflu(®)). Surveillance in hospital or intensive care unit may be necessary. Vaccination against influenza provides a satisfactory immunity in pregnant women and reduces the risk of respiratory complications. Transplacental passage of maternal antibody protects newborns who are more likely to have severe influenza infection and because the vaccine cannot be administered before the age of 6 months. The available data show good tolerance influenza vaccination performed during pregnancy. Since 2012, vaccination against seasonal influenza is recommended for pregnant women, whatever the stage of pregnancy at the time of the vaccination campaign.

Correlation between emergency room visits for influenza-like illness during the influenza A (H1/N1) pandemic in children and adults

Surveillance of incident influenza‐like illness (ILI) was implemented in two children and adult medical emergency departments during the influenza A (H1/N1) pandemic to assess correlations in the daily number of ILI‐related emergency room visits (ERV) between these departments. A total of 7165 ILIs in children and 610 ILIs in adults were observed. We noticed a high linear correlation between the number of ERV involving ILI on day D in the pediatric department and the number of ERV because of ILI 2 days later in adults (R = 0·82, P < 10⁻⁴). Therefore, the rate of adult ILI‐related ERV might be anticipated based on the rate of pediatric ERV.

Extracoronary echocardiographic findings as predictors of coronary artery lesions in the initial phase of Kawasaki disease

OBJECTIVE

To describe the significance of pericardial effusion (PE), mitral regurgitation (MR) and impaired systolic function in predicting coronary artery lesions (CAL) at diagnosis and follow-up in Kawasaki disease (KD).

DESIGN

Echocardiographic records on admission, at 1-3 weeks of illness, and at 6-8 weeks of illness were retrospectively retrieved in children with acute KD treated by intravenous immunoglobulins.

SETTING, PATIENTS

The study included 194 consecutive children (113 male; median age 2.1 years) in a paediatric cardiology tertiary care centre, from 1988 to 2007.

RESULTS

Overall, children with CAL (64/194) were more likely to have PE (OR=3.00, CI 1.34 to 6.72) and MR (OR=2.51, CI 1.22 to 5.16) at diagnosis; PE was the sole echocardiographic abnormality associated with CAL in multivariable analysis. These abnormalities were predictive of the presence of CAL at the first echocardiography in the acute phase of the disease only. MR, systolic dysfunction and PE were not associated with persistence of CAL in the convalescent phase. Male gender, CAL size and resistance to immunoglobulin treatment were independent factors predictive of the persistence of CAL.

CONCLUSIONS

Children with MR or PE should undergo careful assessment of coronary status at diagnosis. However, PE or MR at diagnosis is not predictive of persistent CAL at follow-up.

Adherence to antiretroviral therapy and acceptability of planned treatment interruptions in HIV-infected children

There have been no paediatric randomised trials describing the effect of planned treatment interruptions (PTIs) of antiretroviral therapy (ART) on adherence, or evaluating acceptability of such a strategy. In PENTA 11, HIV-infected children were randomised to CD4-guided PTIs (n = 53) or continuous therapy (CT, n = 56). Carers, and children if appropriate, completed questionnaires on adherence to ART and acceptability of PTIs. There was no difference in reported adherence on ART between CT and PTI groups; non-adherence (reporting missed doses over the last 3 days or marking <100 % adherence since the last clinical visit on a visual analogue scale) was 18 % (20/111) and 14 % (12/83) on carer questionnaires in the CT and PTI groups respectively (odds ratios, OR (95 % CI) = 1.04 (0.20, 5.41), χ² (1) = 0.003, p = 0.96). Carers in Europe/USA reported non-adherence more often (31/121, 26 %) than in Thailand (1/73, 1 %; OR (95 % CI) = 54.65 (3.68, 810.55), χ² (1) = 8.45, p = 0.004). The majority of families indicated they were happy to have further PTIs (carer: 23/36, 64 %; children: 8/13, 62 %), however many reported more clinic visits during PTI were a problem (carer: 15/36, 42 %; children: 6/12, 50 %).

Long-term critical issues in pediatric renal transplant recipients: a single-center experience

Data on long-term outcomes after pediatric renal transplantation (Tx) are still limited. We report on a 20-year single-center experience. Medical charts of all consecutive pediatric Tx performed between 1987 and 2007 were reviewed. Data of patients who had been transferred to adult units were extracted from the French databases of renal replacement therapies. Outcomes were assessed using Kaplan-Meier and Cox models. Two hundred forty Tx were performed in 219 children (24.1% pre-emptive and 17.5% living related donor Tx). Median age at Tx was 11.1 years and median follow-up was 10.4 years. Patient survival was 94%, 92%, and 91% at 5, 10, and 15 years post-Tx, respectively. Overall, transplant survival was 92%, 82%, 72%, and 59% at 1, 5, 10, and 15 years post-Tx, respectively. The expected death-censored graft half-life was 20 years. Sixteen patients developed malignancies during follow-up. Median height at 18 years of age was 166 cm in boys and 152 cm in girls with 68% of patients being in the normal range. The proportion of socially disadvantaged young people was higher than in general population. Excellent long-term outcomes can be achieved in pediatric renal Tx, but specific problems such as malignancies, growth, and social outcome remain challenging.

Viral and bacterial pathogens identification in children hospitalised for severe pneumonia and parapneumonic empyema

Pneumonia is caused by respiratory bacteria and/or viruses. Little is known if co-infections are an aggravating factor in hospitalised children with severe pneumonia. We studied the impact of respiratory pathogens on the severity of pneumonia. Between 2007 and 2009, 52 children hospitalised with a well-documented diagnosis of community-acquired pneumonia (CAP), with or without parapneumonic empyema (PPE), were enrolled in the study. The patients were classified into 2 groups: CAP + PPE (n = 28) and CAP (n = 24). The identification of respiratory viruses and bacteria in nasopharyngeal aspirates and pleural effusion samples were performed using conventional bacterial techniques and molecular assays. Using real-time multiplex PCR and antigen detection, Streptococcus pneumoniae was the main agent identified in 76% of the cases by molecular tests and BinaxNOW® in pleural fluid. A total of 8% of pleural fluid samples remained undiagnosed. In nasopharyngeal aspirates, rhinovirus, parainfluenza viruses, human metapneumovirus, and respiratory syncytial virus were detected in both CAP and CAP + PPE populations; however, the percentage of viral co-detection was significantly higher in nasopharyngeal aspirates from CAP + PPE patients (35%) compared with CAP patients (5%). In conclusion, viral co-detection was observed mainly in patients with more severe pneumonia. Molecular biology assays improved the pathogens detection in pneumonia and confirmed the S. pneumoniae detection by BinaxNOW® in pleural effusion samples. Interestingly, the main S. pneumoniae serotypes found in PPE are not the ones targeted by the heptavalent pneumococcal conjugate vaccine.

[Social representations of vaccination among patients and general practitioners: a study based on hierarchized evocation]

In France, there is a discrepancy between perceptions and practices related to vaccination, the causes of which are poorly understood. The purpose of this study was to examine and compare patients' and physicians' social representations of vaccination. A qualitative study based on hierarchized evocation was conducted on a sample of 30 patients and 30 general practitioners. The participants were asked to write down seven words or word groups (word associations) induced by the concept of "vaccination" and to rank them in order of importance. The associations were grouped by theme and sub-theme. Their frequency, connotations and importance were compared between the two groups. The results show that, overall, the physicians had a positive view of vaccination, while the patients had a more neutral view (polarity index: + 0.38 vs + 0.07, p &lt; 0.01). Among both patients and general practitioners, vaccination tends to be perceived as a form of medical care mainly targeting children and aimed at prevention, and its effectiveness is considered to be implicit. However, the patients appeared to be more concerned about the potential side effects of certain vaccinations, while the GPs emphasized the harmlessness of vaccination. The participating GPs also tended to take a collective view of vaccination, while some patients criticized the lack of targeted vaccinations. Better communication on these key aspects of representations may help to increase confidence in vaccination and to close the gap between perception and practice.

Survey of delivery of prophylactic immunoglobulins following exposure to a measles case

In France, almost 23,000 cases of measles and 10 deaths have been reported between January 2008 and August 2012. French health authorities recommend delivery of human polyvalent immunoglobulins in the event of exposure to a measles case for some categories of unvaccinated persons (children under the age of 12 months, immunocompromised persons and pregnant women), within six days after exposure and following laboratory confirmation of the contact case. We carried out a postal survey among 368 French hospital pharmacies to evaluate the number of persons affected by this measure between 1 January 2010 and 31 August 2011, to describe the characteristics of these patients and to evaluate the application of the recommendations in terms of delay between exposure and immunoglobulin delivery, and confirmation of the contact case. The response rate to the survey was 73%. In total, 400 immunoglobulin deliveries were listed, most of them for children under the age of one year, and 84% of the 250 administrations with available information occurred within six days after exposure, as recommended. However, only 48% of the 209 treated contacts with available information were laboratory-confirmed when the immunoglobulins were delivered. This survey is the first evaluation of this recommendation since its introduction in 2005 and suggests that the recommendations may need to be updated.

Macrolide-resistant Bordetella pertussis infection in newborn girl, France

A macrolide antimicrobial drug was administered to a newborn with cough. On day 23 of hospitalization, macrolide-resistant Bordetella pertussis was isolated from nasopharyngeal aspirates. DNA sequencing and PCR-restriction fragment length polymorphism showed a 2047 A-to-G mutation in the 3 copies of the 23S rRNA gene. Monitoring for macrolide resistance is essential in infants <6 months of age.

A report on the large measles outbreak in Lyon, France, 2010 to 2011

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A report on the large measles outbreak in Lyon, France, 2010 to 2011

In 2010 and 2011, the city of Lyon, located in the Rhône-Alpes region (France), has experienced one of the highest incidences of measles in Europe. We describe a measles outbreak in the Lyon area, where cases were diagnosed at Lyon University hospitals (LUH) between 2010 and mid-2011. Data were collected from the mandatory notification system of the regional public health agency, and from the virology department of the LUH. All patients and healthcare workers who had contracted measles were included. Overall, 407 cases were diagnosed, with children of less than one year of age accounting for the highest proportion (n=129, 32%), followed by individuals between 17 and 29 years-old (n=126, 31%). Of the total cases, 72 (18%) had complications. The proportions of patients and healthcare workers who were not immune to measles were higher among those aged up to 30 years. Consequently, women of childbearing age constituted a specific population at high risk to contract measles and during this outbreak, 13 cases of measles, seven under 30 years-old, were identified among pregnant women. This study highlights the importance of being vaccinated with two doses of measles vaccine, the only measure which could prevent and allow elimination of the disease.

[Wakefield's affair: 12 years of uncertainty whereas no link between autism and MMR vaccine has been proved]

In 1998, a Lancet paper described 12 cases of children with autism, and having been vaccinated (MMR) in the United Kingdom; medias presented the information to the lay public, stating that a link was possible. In 2004, The Lancet published letters responding to allegations against the paper. Later, it was established that no link existed between MMR and autism; few years and many publications were necessary to conclude to the absence of evidence. In 2010, the General Medical Council published a report against Dr Wakefield, first author of the 1998 paper, and showing that the children hospital records did not contain the evidence; hospital records differed from the published paper; the Lancet retracted the 1998 paper. In 2011, Brian Deer, a journalist, published the complete story in theBMJ: in 1996, Wakefield was approached by lawyers representing an anti-vaccine lobby, and they supported the Wakefield research. Dr Wakefield left England; in 2012 he works in Texas, USA, for anti-vaccine lobbies.

Human parechovirus infections, Lyon, France, 2008-10: evidence for severe cases

BACKGROUND

Although data documenting the frequency and severity of human parechovirus type 3 (HPeV-3) infection in infants have been published in Canada, the USA, the UK and the Netherlands, no data from France are available.

OBJECTIVES

To determine the detection frequency of HPeV in cerebrospinal fluid (CSF) samples collected from children aged <5 years hospitalized between 2008 and 2010 in the University Hospital of Lyon and to describe the clinical, virological and biological characteristics associated with HPeV infection.

STUDY DESIGN

A total of 1128 CSF samples were retrospectively tested using the Parechovirus-Rgene™ real-time RT-PCR assay. Positive samples were typed by sequencing using the CDC method. Retrospective analysis of the medical charts was performed.

RESULTS

Over a 3-year period, 33/1128 (2.9%) CSF samples were found to be HPeV-positive. In 2010, 9.3% of the children aged <3 months (32% in June) were detected HPeV-positive. The median age at diagnosis was 26 days (8-131 days). Most patients (86%) presented with fever or a sepsis-like syndrome. Three patients (2 with septic shock syndrome, 1 with severe respiratory distress) required hospitalization in an intensive care unit. An HPeV-3 acute infection was identified in an 11-day-old girl who died from sudden infant death syndrome. Of 29 patients genotyped, 28 were infected with HPeV-3 and one with HPeV-4.

CONCLUSIONS

HPeV is a significant cause of sepsis and severe sepsis in children <3 months. Routine screening for HPeV in CSF and blood should thus be performed more extensively and could improve clinical management.

Pediatric neurological complications associated with the A(H1N1)pdm09 influenza infection

BACKGROUND

Influenza-related neurological complications (INC) have been reported during seasonal flu in children.

OBJECTIVES

To investigate the types, outcomes and incidence of INC occurring during the 2009 A(H1N1) pandemic, a retrospective analyze was conducted in the single French pediatric hospital of Lyon from October 2009 to February 2010.

STUDY DESIGN

All children presenting with fever, influenza-like illness, respiratory distress or neurological symptoms were tested for influenza A(H1N1)pdm09 infection from respiratory specimens using real time RT-PCR.

RESULTS

INC occurred in 14 A(H1N1)pdm09 positive children (7.7% of A(H1N1)pdm09 positive children admitted to hospital) with a median age of 5.1 years. Admission to the intensive care unit (ICU) was required for nine children (64.3%). Half of the children with INC had comorbidity and three had coinfection, both characteristics mainly found in children requiring the ICU. All children received oral oseltamivir treatment. Febrile seizures were observed in eight children, half of them having a chronic comorbidity (2 epilepsy, 1 nonketotic hyperglycinemia, 1 anoxic encephalopathy). Other INC, less commonly reported, included 2 cases of encephalitis, 1 encephalopathy, 1 basilar artery thrombosis, 1 myasthenic crisis and 1 coma. Eleven of the 14 children (78.6%) recovered, one had a minor disability, one child developed a locked-in syndrome and one died from complications of an acute necrotizing encephalopathy.

DISCUSSION

INC can be observed even in children with no underlying disorder. It may lead to dramatic issue in a significant number of cases.

[Measles and pregnancy]

Because of insufficient vaccine coverage, there is an outbreak of measles since 2008 in France with an increasing incidence of cases, most of them among children less than 1 year old or young adults. When measles occurs during pregnancy, maternal and fetal morbidity is increased. Particularly pregnant women are exposed to a higher risk of severe respiratory distress that might cause death. Measles virus can be detected in the placenta. Placental infection appears to be involved in some cases of fetal death. The virus is not responsible for congenital defects but can induce histologic damages inside the placenta which may lead to fetal death. Major perinatal risks are also miscarriage and prematurity. When measles occurs in late pregnancy, congenital infection is possible with variable expression and a risk of subacute sclerosing panencephalitis. Non immune pregnant women or neonates exposed to measles should receive an immunoglobulin prophylaxis within 6 days after contact in order to reduce the risk of infection and severe morbidity. In case of declared measles infection, symptomatic treatment can be proposed and tocolysis can be used if preterm labor is associated. Daily fetal monitoring during the 14 days following the beginning of the eruption can be offered when the fetus is viable. Vaccination is recommended for the people born in France after 1980 with 2 doses of vaccine against measles, rubeola and mumps. Measles vaccine, an attenuated living vaccine, should not be administered during pregnancy but must be proposed before pregnancy or during the post-partum period.

Pragmatic management of Panton-Valentine leukocidin-associated staphylococcal diseases

Panton-Valentine leukocidin (PVL)-producing Staphylococcus aureus is associated with a broad spectrum of diseases, ranging from common uncomplicated soft tissue infections to severe diseases such as complicated soft tissue infections, extensive bone and joint infections, and necrotising pneumonia. Specialised management of infection based on the presence of PVL may not be required for mild infections, whereas it could be lifesaving in other settings. Moreover, most severe PVL diseases are recently identified entities and a 'gold standard' treatment from comparatives studies of different therapeutic options is lacking. Thus, recommendations are based on expert opinions, which are elaborated based on theory, in vitro data and analogies with other toxin-mediated diseases. In this review, we consider the potential need for specialised PVL-based management and, if required, which tools should be used to achieve optimal management.

[Resistance to immunization]

Despite a well documented efficacy and a generally good adhesion of a large majority of the lay population and health care professionals as well, immunization is still the object of controversies. It affects several vaccines against hepatitis B, influenza, BCG, pertussis and measles. In most cases, polemics on vaccination result from a temporal association between a vaccination and the revelation of a serious disease, when the immunization is performed at the peak of incidence of the disease. Controversies can also be initiated by scientific publications, even though these are often biased, by a misinterpretation or the absence of official positions from the health care authorities, or by justice decisions, whose criteria differ from the scientists' ones and are therefore difficult to understand for the lay public. Furthermore, the scientific demonstration of the exclusion of a risk is difficult to obtain. In the past, it appeared to be very difficult to stop controversies. Improving the communication is the main issue, towards lay public as well as health care professionals. This implies to learn how to better use the media, to motivate and educate professionals who administer vaccine, and anticipate the eventuality of a temporal relationship between vaccination and occurrence of a serious disease by an improved management of the pharmacovigilance system.

Respiratory viruses in children admitted to hospital intensive care units: evaluating the CLART® Pneumovir DNA array

Viruses play a significant part in children's respiratory infections, sometimes leading to hospitalization in cases of severe respiratory distress. The aim of this study was to investigate respiratory infections in children treated in a hospital intensive care unit (ICU). Assays were performed using the CLART® Pneumovir DNA array assay (Genomica, Coslada, Madrid, Spain), which makes it possible to detect 11 genus of respiratory viruses simultaneously. During the winter of 2008–2009, 73 respiratory specimens collected from 53 children under 2 years of age and admitted to an ICU were tested. At least one virus was detected in 78% (57/73) of the samples. The virological diagnosis was based on single infections in 65% (37/57) and on multiple infections in 35% (20/57) of cases. The array assay revealed respiratory syncytial virus (RSV) in 73.6% (42/57) of the samples and rhinovirus in 24.6% (14/57), either on their own or in co‐infections. All viruses identified in single and multiple infections were tested, taking into account clinical features, risk factors, and severity criteria. Children with no risk factors presented more multiple infections, up to 42% of cases, than children with at least one risk factor. RSV seemed to induce severe symptoms by itself as no difference in intubation needs was observed when RSV was detected on its own or in co‐infection. The CLART® Pneumovir DNA array was useful for examining severe viral respiratory infections, when other viruses than those detected by conventional methods could be involved, particularly in an ICU. J. Med. Virol. 83:150–155, 2011. © 2010 Wiley‐Liss, Inc.

[Measles vaccination]

France is facing since 2008 a re-emerging measles outbreak affecting a high proportion of adults currently not or not correctly vaccinated. The non application since 30 years of the immunization program on measles mumps and rubella is the cause of this situation, despite the efficacy and the good tolerance of this vaccine has been demonstrated. The present epidemic is expected to go on, as long as the millions of measles susceptible people have not been either affected or vaccinated. A 95% protection rate is needed to interrupt the circulation of the virus. So, the objective of the French Plan for elimination of measles and congenital rubella is to reach at least a 95% vaccination coverage for the first dose and 80% for the second dose. The immunization recommendations should be strictly respected: first dose of MMR vaccine at 12 months and second dose within the second year of life. In this context, catch up immunization of children, adolescents and young adults (up to 30 year) not or not correctly vaccinated is particularly important, as well as the post exposure prophylactic measures, including vaccination.

Spotlight on measles 2010: update on the ongoing measles outbreak in France, 2008-2010

Since early 2008, France has been experiencing a measles outbreak with almost 5,000 notified cases as of 30 June 2010, including three measles-related deaths. The proportion of cases 20 years or older reached 38% during the first half of 2010. This situation is the consequence of insufficient vaccine coverage (90% at age 24 months in 2007) that led to the accumulation of susceptibles over the last years. It underlines the need for additional measures targeting susceptible children and young adults.

Spotlight on measles 2010: Update on the ongoing measles outbreak in France, 2008-2010

Since early 2008, France has been experiencing a measles outbreak with almost 5,000 notified cases as of 30 June 2010, including three measles-related deaths. The proportion of cases 20 years or older reached 38% during the first half of 2010. This situation is the consequence of insufficient vaccine coverage (90% at age 24 months in 2007) that led to the accumulation of susceptibles over the last years. It underlines the need for additional measures targeting susceptible children and young adults.